Mental Health and Substance Abuse

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Mental Health and Substance Abuse

• An Overview for Emergency Medical Service
  Responders
• Joanne Mc Lain, Ph.D., LPC, LAC

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Overview

• Major Mental Illness
• Dementia and Delirium
• Psychiatric Medications
• Domestic Violence
• Substance Abuse
• Emergency Mental Health Law
• Mental Status Exams
• Disaster Response Crisis Counseling
• Vicarious Trauma

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Major Mental Illness

• Depression
• Bipolar Disorder
• Anxiety Disorders
• Post Traumatic Stress Disorder
• Schizophrenia and Other Psychosis
• Axis II Disorders

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Depression

• Major Depression
• Five or more symptoms present for at least two
  weeks, cause clinically significant distress or
  impairment
• Depressed mood
• Diminished interest in activities
• Change in appetite
• Change in sleep patterns
• Psychomotor Agitation or Retardation
• Fatigue or loss of energy
• Feelings of worthlessness or excessive guilt
• Diminished ability to think or concentrate
• Recurrent thoughts of death

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Other Forms of Depression

• Dysthymia
• Bereavement
• Adjustment Reaction
• Due to a Medical Condition
• Substance-Induced Depression

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Bipolar Disorder

• Manic episode a distinct period of abnormally
  and persistently elevated, expansive, or
  irritable mood, lasting at least one week,
  causing marked impairment in functioning.
• During manic episode, 3 or more symptoms
• Inflated self-esteem or grandiosity,
• Decreased need for sleep,
• More talkative or pressure to keep talking,
• Flight of ideas or racing thoughts,
• Distractibility,
• Increase in goal-directed activity or
  psychomotor agitation,
• Excessive involvement in pleasurable activities
  that have a high potential for painful
  consequences.

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Suicide

• High risk demographics divorced, unemployed
  male, over 45, living alone, no religious
  affiliation.
• Ideation
• Plan
• Means
• History
• Psychosocial Stressors

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Anxiety Disorders

• Panic Disorder
• Agoraphobia
• Specific Phobias
• Obsessive-Compulsive Disorder
• Generalized Anxiety Disorder
• Substance-Induced Anxiety Disorder

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Post-Traumatic Stress Disorder

• Experienced or witnessed a traumatic event that
  involved actual or threatened death or serious
  injury to self or others.
• Response involved intense fear, helplessness, or
  horror.
• Traumatic event is persistently reexperienced.
• Persistent avoidance of stimuli associated with
  the trauma and numbing of general responsiveness.
• Persistent symptoms of increased arousal.
• Duration of symptoms more than 1 month.
• Causes clinically significant impairment.

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Schizophrenia

• First recognized symptoms often occur between
  ages 16 and 25.
• Positive symptoms delusions, hallucinations,
  disorganized speech, disorganized or catatonic
  behavior.
• Negative symptoms flat affect, alogia,
  avolition.
• Marked decrease in basic social, occupational,
  self-care functioning.
• Types Paranoid, Disorganized, Catatonic,
  Undifferentiated
• Related disorders Schizoaffective, Delusional,
  Brief Psychotic, Shared Psychotic, Psychotic
  Disorder due to Medical Condition or
  Substance-Induced.
• Major Depression may include psychotic symptoms.

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Axis II Disorders

• Personality Disorders an enduring, pervasive and
  inflexible pattern of inner experience and
  behavior that deviates markedly from expectations
  of persons culture. Cognition, affectivity,
  interpersonal functioning, impulse control.
  Leads to clinically significant impairment in
  social, occupational, other areas of functioning.
• Paranoid, Schizoid, Schizotypal
• Antisocial, Borderline, Histrionic, Narcissistic
• Avoidant, Dependent, Obsessive-Compulsive

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Dementia

• Development of Multiple Cognitive Deficits
• Memory Impairment
• Aphasia, Apraxia, Agnosia, Disturbance in
  Executive Functioning
• These deficits represent a significant decline
  from previous level of functioning and are long
  term
• Can be with Delirium, Delusions, or Dementia
• Alzheimers, Vascular, Other Medical Conditions
• Ex HIV, Head Trauma, Parkinsons, Huntingtons,
  Picks, Creutzfeldt-Jakob, Hydrocephalus,
  Hypothyroidism, Brain Tumor, B12
  Deficiency,Intracranial Radiation

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Delirium

• Disturbance of consciousness (reduced clarity of
  awareness of the environment) with reduced
  ability to focus, sustain, or shift attention.
• Develops over a short period of time.
• Tends to fluctuate during the course of the day.
• Differential diagnosis delirium develops quickly
  and the person is not alert, unlike dementia
  (although these conditions can coexist).
  Hallucinations, delusions and disordered thinking
  tend to be random and haphazard, unlike
  schizophrenia.
• Delirium is a medical emergency. Dont assume
  the cause is only alcohol intoxication or
  withdrawal until the client has been medically
  cleared. Alcohol withdrawal can also have
  serious medical consequences.

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Psychiatric Medications

• Anti-Psychotics
• Anti-Depressants
• Anxiolytics
• Mood Stabilizers (Anti-manic)
• ADHD

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Attention-Deficit/Hyperactivity Disorder

• Ritalin (methylphenadate hydrochloride)
• 5 to 20 mg., also SR 20 mg.
• Aderall (dextroamphetamine and amphetamine)
• 5 to 40 mg.
• Dexedrine (dextroamphetamine sulfate)
• 5 to 40 mg., also Spansule SR capsules

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Domestic Violence
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Substance Abuse

• Alcohol
• Marijuana
• Methamphetamine
• Cocaine
• Prescription Drugs
• Designer Drugs
• Heroin
• Self-medication and trauma response

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Emergency Mental Health Law

• CRS 27-10
• Any person who appears to be mentally ill and, as
  a result of such mental illness, appears to be an
  imminent danger to self or others, or appears to
  be gravely disabled, may be involuntarily
  detained.
• People who can sign a 72-hour hold (M1)
• Peace Officer
• Licensed Psychologist or Physician
• LCSW, LPC, LMFT
• BSN with 1 year psychiatric nursing experience
• MSN with training in psychiatric nursing
• RN certified as a Clinical Specialist in
  Psychiatric Nursing

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• A court may order a person to be taken into
  custody for 72-hour evaluation and treatment with
  an affidavit affirmed before a judge which
  relates sufficient facts to establish the
  appearance of mental illness and imminent danger
  to self or others, or grave disability.
• Reasonable effort to secure personal property.
• Purpose of evaluation and Rights of Patients must
  be explained (M2).
• The court may issue an order to the sheriff to
  transport to a treating facility (M18).
• Treating facility may choose to extend the period
  of involuntary treatment with a certification.
• 15 year-old children can be treated voluntarily,
  regardless of parental consent.

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Psychiatric Hospitals

• A patient on an M1 or M3 hold must be taken to a
  27-10 facility.
• They may be screened at another hospital.
• CMHI-Ft. Logan and CMHI-Pueblo are the state
  psychiatric hospitals.
• Porters, University, Denver Health,
  Presbyterian-St. Lukes, Penrose-St. Francis,
  West Pines, Cleo Wallace, Cedar Springs.

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Mental Status Exam

• Appearance/Behavior dress, posture, motor
  activity, physical characteristics, reaction to
  interviewer, mannerisms
• Orientation Person, Place, Time, Situation
• Memory recent, remote
• Cognitive information and vocabulary, attention,
  concentration, abstract reasoning, thought
  content and process
• Speech rate, tone, loudness, pronunciation,
  organization
• Judgement/Insight understanding of social norms,
  events that led to current situation, personal
  role
• Affect observable emotional indicators
• Mood subjective emotional state, not as variable

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Disaster Response and Crisis Counseling

• Exposure to disaster causes psychological trauma
  to individuals and communities.
• Stress and grief reactions are normal responses
  to abnormal situations.
• Pre-existing stressors increase trauma reactions.
• Most people do not think they need mental health
  services after a disaster.
• Crisis counseling involves outreach, education,
  practical assistance, normalizing reactions, and
  a focus on building strengths for the
  individual/community to handle present concerns.
  Model Non-Anxious Presence.
• Social support systems are crucial to recovery
• Interventions must fit the phase of the disaster.

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Exposure to Trauma

• Experience of a perceived inescapable horror,
  with the fear of bodily injury or death.
• An interaction of who you are, what happened, and
  the context in which it happened.
• Can cause changes in the way the brain works.
• Traumatic memory is different from ordinary
  memory
• Stored on the right side emotional, kinesthetic,
  artistic, behavioral sequences, images.
• It does not fade over time.
• State-dependent, amygdala process.
• Involuntary flashbacks and intrusive dreams,
  4Fs.
• Can result in Major Depression, PTSD, Anxiety
  Disorder, increase in domestic violence and
  substance abuse.
• Early intervention while brain is plastic is
  very important.

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Vicarious Traumatization

• Cumulative, transformative, effect of working
  with traumatized people.
• Can result in burnout exhaustion,
  depersonalization, decline in sense of personal
  effectiveness.
• Degree to which you are responsible and
  committed to your work is the degree to which you
  are susceptible to vicarious traumatization.
  Empathy is a double-edged sword.
• Effects similar to primary traumatization
  safety, trust, esteem, intimacy, control,
  sensory. Leads to exhaustion, depersonalization,
  lack of efficacy, substance abuse, relationship
  disruption, judgement errors, boundary
  violations, systemic conflict.
• Numb-ers vs. Intruders

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Managing Vicarious Trauma

• Awareness Manage exposure, manage your health,
  manage the meaning
• Balance Set limits, schedule time for pleasant
  activities, get out of beeper range, develop a
  weird sense of humor.
• Connection spend time with people who do other
  work, keep your team healthy, have a defusing
  partner.
• Know your own signs of stress.
• Protective factors Exercise, experience,
  satisfying personal relationships, buddying up,
  understanding the importance and meaning of what
  you do.